Fit4Life Power Slam Registration Form
Event Date:
December 4, 2021
Location:
Fit4Life, 210 Owen Drive, Fayetteville, NC 28304
Event Date:
Saturday December 4, 2021
Meet Host:
Fit4Life, Mr. Cruiz
Venue Phone:
(910) 491-6860
Federation President:
Bill Clary
Sanction by:
365 Strong World Powerlifting Federation (365 SWPF)
Classification Options: >Tested >Untested
Divisions: >Open >Juniors (20-23) >Sub-Masters (35-39) >Masters >M/P/F >Teenage >Youth (11-12) >Para-lifter >Novice >Kids Club (10 & under)
Lifting Categories
: >"Raw" >"Raw Classic" >"Single-Ply" >"Multi-Ply"
Competitive Events:
>Full Power >Push Pull >Squat Only >Bench Press Only >Deadlift Only >Strict Curl
Early Weigh–Ins:
Friday, December 3, 2021: 10:30am – 12:30pm and 4:00-6:00pm. (at meet site)
Late Weigh-ins:
Saturday, December 4, 2021: 7:00-8:00am (by approval only)
Eligibility:
Open to all athletes with an active 365 SWPF Membership. Lifetime Memberships (one-time fee) are $55 and Annually renewable memberships are $30.
Standard Full Power Entry Fee:
$100
Special Full Power Fees (for M/P/F, Teens & Youth):
$85
Push Pull and Single Lift (SQT, BP, DL) Entry Fee:
$85
Crossover and/or Strict Curl Fee:
$50 (entering an additional division)
Team Entry Fee:
$60
Kids Club Participation Fee:
$25
Deadline/Late Entries:
All Entries MUST be received by
November 18, 2021
or be charged a Late Entry Fee of $50. THIS EVENT WILL BE LIMITED TO 48 ENTRIES, no more entries will be accepted once this quota is met!
Uniform:
Mandatory - Must have one piece lifting suit or wrestling singlet. 365 SWPF rules apply @ 365strong.org.
Meet Day Agenda:
Mandatory rules briefing: Saturday @ 8:00am; Lifting Begins at approximately 9:00am
Awards:
1-3rd place in all Division Weight Classes, Tested & Untested Best Lifters and Team Champion
Weight Classes - Women:
97.0, 105¾, 114½, 123½, 132¼, 148¾, 165¼, 181¾, 198¼, and 198.26+
Weight Classes - Men:
114½, 123½, 132¼. 148 3/4, 165¼, 181¾, 198¼, 220¼, 242½, 275½, 308¾ and SHW
Methods of Payment:
Mail Check to: “365 SWPF” Website: 365strong.org (PayPal online)
Check or Money Order Mailing Address:
365 SWPF, PO Box 253, Fort Mill, SC 29716
Federation Contact Info:
Bill Clary: 704/236-1899
Email:
info@365strong.org
RELEASE OF LIABILITY WAIVER (READ BEFORE SIGNING and return with entry form with entry fee)
In consideration of being allowed to participate in any way in the
2021 Fit4Life Power Slam
, Sanctioned by 365 SWPF, its related events and activities, I The undersigned, acknowledge, appreciate, and agree that: 1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and, 3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the meet officials immediately; and, 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS THE Meet Host – Tyler Dixon and Fit4Life Gillis Hill, city of Fayetteville, NC, Host staff, 365 SWPF President - Bill Clary, 365 Strong World Powerlifting Federation LLC, any gym or meet representatives, 365 SWPF officers, meet referees, all event personnel, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity ("Releases"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, ILLNESS, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. 5. I willingly allow 365 Strong World Powerlifting Federation to use my photos or videos to promote my accomplishments and I approve the use of my photos or videos in federation marketing materials. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. ____________________________________________________________________ ____________ ___________________ PARTICIPANT'S SIGNATURE AGE DATE FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT TIME OF REGISTRATION) This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releases, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releases from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law. ___________________________________________________________ ___________________________ ____________ PARENT/GUARDIAN SIGNATURE PHONE DATE
Name
Address:
City, State, Zip:
Email
Phone
Other Phone
Date of Birth:
Home (Team) Gym:
Competitive Highlight:
Records:
Membership Status:
Enter Yes (you applied today) or No (you will apply at weigh-ins)
Classification Entered:
Enter "Tested" or "Untested"
Lifting Preference:
You may change your preference at weigh-ins.
Raw (knee sleeves permitted)
Raw Classic (knee wraps permitted)
Equipped Single-Ply
Unlimited Geared Multi-Ply
Divisional Categories Entering:
What FULL POWER categories do you plan to enter:
Open
Juniors (20-23)
Novice (Class II & Below)
Sub-Masters (35-39)
Masters
M/P/F
Teenage
Youth (11-12)
Para-lifter
Kids Club (deadlift only)
Competition Categories Entering:
Full Power
Push Pull
Squat Only
Bench Only
Deadlift Only
Strict Curl
Men's Weight Class Entering:
114.5 lb/52 kg
123.5 lb/56 kg
132.25 lb/60 kg
148.75 lb/67.5 kg
165.25 lb/75 kg
181.75 lb/82.5 kg
198.25 lb/90 kg
220.25 lb/100 kg
242.5 lb/110 kg
275.5 lb/125 kg
308.75 lb/140 kg
308.8+ lb/140.1+ kg
Women's Weight Class Entering:
97.0 lb/44 kg
105.75 lb/48 kg
114.5 lb/52 kg
123.5 lb/56 kg
132.25 lb/60 kg
148.75 lb/67.5 kg
165.25 lb/75 kg
181.75 lb/82.5 kg
198.25 lb/90 kg
198.26+ lb/90.1+ kg
I agree to abide by all terms of the Entry Information and the Waiver General Release:
YES
NO
Meet T-Shirt Size:
Adult S
Adult M
Adult L
Adult XL
Adult 2-XL
Adult 3-XL
Adult 4-XL
Kids Size (enter in comments)
Walk-up Lifting Song
Please provide the name of your song and artist.
Lifter Name Confirmation
Parent or Guardian Approval (if under 18 years old)
Comments
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